Nurse Practitioners have long been discussed as a potential solution to capacity issues in some areas of health. In Australia however, they have failed to gain momentum. In this post Mack Madahar explores the confusion about the role and provides clear definitions to differentiate Nurse Practitioners from the more traditional Practice Nurse role.
Mack Madahar writes:
The lack of distinction between NP (Nurse Practitioner) and PN (Practice Nurse) roles has lead to role confusion and hindered the acceptance of NPs working in PHC (Primary Health Care).
There is genuine support for Practice Nurses amongst the medical profession in Australia. Practice nurses appear to fit neatly into existing cultural perceptions and practices, and are perceived as an integral part of the general practice team.
This support sits in stark contrast to the opposition from some medical practitioners to alternative practitioners, particularly Nurse Practitioners. As early as 2005 the AMA warned against nurse practitioners suggesting that they would “be consigning patients in areas of workforce need to inferior health care.” An article published this week in the MJA is an eloquent example of the concerns of medical practitioners and the turf war that seems to be taking place.
The article in the MJA provides a good insight into the lack of understanding of the NP role in the PHC context. The article provides contradictory statements regarding the NP role to the article it sources. The original article highlights the lack of difference in primary care provided by APNs (Nurse Practitioners) and physicians and for some measures it mentions care provided by NP as superior. Furthermore it points out the NP workforce as well positioned to provide safe and effective primary care.
A widespread lack of knowledge of the type of services offered by Nurse Practitioners may be further confounding the issue. Unless medical practitioners have worked with or have prior knowledge of NP scope of practice, it is often difficult to realise the benefits NPs offer to the practice and their patients.
When services offered by PHC-NPs are evaluated, however, the value added service offered by NPs has never been in question, neither has NP’s ability to deliver care that is clinically appropriate and safe.
There are abundant examples of NPs able to be see patients in an independent capacity (diagnose, prescribe, refer, manage and review) allowing GPs to focus on chronic/complex issues. The ability of NPs when performing procedures such as contraception insertion/removal, punch biopsies, wedge resections, interpreting spirometry’s, ECG and PAP smears have never been fully utilised. These examples provide only a glimpse to the potential and robust nature of the NP workforce within the PHC domain.
Nurse practitioners could have an important role in enabling primary health care services to deliver cost effective and timely healthcare in a collaborative manner. Primary health care has the potential to involve and utilise a substantial number of NPs. Yet, the reality remains the handful of NPs working in PHC are struggling with role adaption and appropriate collaborative opportunities.
To promote the NP role within PHC, it is important to define and differentiate the role from that of the practice nurse. The attached table attempts to demystify the two roles to some extent. It provides broad differentiation to appreciate the two roles and moreover how PHC-NP role can add value to any general practice.
Practice Nurse (PN): “Primary health care nurses work in a range of settings, each sharing the characteristic that they are a part of the first level of contact with the health system. In Australia, those settings can include community and general practice. The scope of practice of an individual Registered or Enrolled nurse may be more specifically defined to reflect the individual nurse’s “education, clinical experience and demonstrated competency” in the specific clinical setting.
PHC-Nurse Practitioner (NP): “A nurse practitioner is a registered nurse educated to function autonomously and collaboratively in an advanced and extended clinical role. The role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to diagnosing, direct referral of patients to other health care professionals, prescribing medications, ordering diagnostic investigations and ongoing management of conditions.
Clearly NPs provide scope of practice flexibility and options to practice settings. My experience is that services are cost neutral and PHC-NP ensure practice efficiency. Practice incentive payments (PIP) required to fund practice nurses are not necessary for NPs as they are independent practitioners and funded accordingly.
Evidence suggests NPs work to increase productivity, have time and expertise to cater for patients with chronic and complex disease. When working to their full scope of practice, they assist with providing a level of clinical expertise PNs are not expected to deliver.
In addition, NPs act as role models, clinical facilitators, clinical leaders and mentors for PNs. A growing number of PNs are considering undertaking NP programs. Unfortunately, lack of understanding and opportunities to discuss the NP role within medical fraternity has led to few GPs and practices taking advantage of the PHC-NP experience.
A cost neutral model of NP practice and willingness of PHC-NPs to work under difficult circumstances, such as with limited Medicare item numbers, is substantial proof that NPs have altruistic reasons when calling for greater acceptance and collaboration of the role within private practices. Yet this has proven to be extremely difficult.
Lack of knowledge and acceptance amongst our medical colleagues has made it tough for PHC-NPs to find their niche within primary health care settings. Of the approx. 1200 endorsed NPs, the number of PHC-NP (inc. mental health NPs) remains small.
A new champion of the role may be the recently announced the Primary Health Care Advisory Group (PHCAG) established to look at the current system and suggest possible reform options for a healthier Medicare.
PHCAG released a background paper that provides an overview of Australia’s primary health care system and examines alternative systems employed overseas. It is refreshing and encouraging that the paper distinguishes the role of nurse practitioners (NP) from nurses (PN) as separate entities.
The potential benefits of Nurse Practitioners have yet to be realised in the Australian primary health context. Australian healthcare consumers have the right to demand a service that is available to them at the time of their need and at a place they can access. It is hoped that PHCAG recommendations include appropriate reimbursement and utilisation of such valuable resource.
Mack Madahar is a primary health and mental health NP. These are his views and not of any organisation.